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03 - BIRTH ASPHYXIA

Birth Asphyxia in newborns<br>

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03 - BIRTH ASPHYXIA

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  1. BIRTH ASPHYXIA BY DR. CLIVE BOWMAN: Dip. Rad; MBBS; M.Med (PAEDIATRICS)

  2. Arch of aorta Fetal Circulation Superiorvena cava Ductus arteriosus Lung Pulmonary trunk Foramen ovale Pulmonary veins Right atrium Left atrium Valve offoramen ovale Right ventricle Left hepatic vein Inferior vena cava Ductus venosus Descending aorta Sphincter Oxygen saturation of blood Portal vein Gut High oxygen content Umbilical vein Medium oxygen content Kidney Urinarybladder Umbilicus Poor oxygen content • Gas exchange in placenta • Alveoli filled with fluid • Pulmonary BV constricted • Systemic pressure low • Pulmonary pressure high • Very little blood flows to lungs Umbilicalarteries Placenta Legs Internal iliac artery

  3. INTRODUCTION • Birth/perinatal asphyxia is a neonatal emergency as it may lead to hypoxia and possible brain damage or death if not correctly managed. • Hypoxic Brain injury secondary to perinatal asphyxia, manifest clinically within 48 hours of birth as hypoxic ischemic encephalopathy (HIE). (acute period) • HIE is associated long term neurological deficit including cerebral palsy (CP).

  4. BIRTH ASPHYXIA: EPIDEMIOLOGY • Worldwide, > 1 million babies die annually from complications of birth asphyxia. • Asphyxia => leading causes of newborn deaths in developing countries • 4-9 million cases of newborn asphyxia each year • Accounts for 20-25% of the infant mortality. • 10% NB require assistance at birth • 1% require extensive resuscitation

  5. DEFINITION • There is no gold standard definition • Since asphyxia may occur in utero, at birth or in the postnataliy, it is probably better to use the term perinatal asphyxia. • The WHO defines perinatal asphyxia as a “failure to initiate and sustain breathing at birth” • Moderate asphyxia: • Slow gasping breathing • Or Apgar score of 4-6 at 1 minute of age. • Severe asphyxia: • No breathing • Or an Apgar score of 0-3 at 1 minute of age.

  6. DEFINITION • AAP and ACOG: • All the following must be present for the designation of asphyxia: • Profound metabolic or mixed academia (pH< 7.00) in cord. • Persistence of Apgar scores 0-3 for longer than 5 minutes. • Neonatal neurologic sequelae (seizures, coma, Hypotonia). • Multiple organ involvement (kidney, lungs, liver, heart, intestine)

  7. CONSEQUENCES OF IN TERRUPTED TRANSITION • Hypotonia • Apnea / gasping respiration • Tachypnea • Bradycardia • Hypotension • Cyanosis

  8. V/S CHANGES DUE TO OXYGEN DEPRIVATION RAPID BREATHING IRREGULAR/GASPING • Axphyxia => Initially, rapid respirations. • Continued asphyxia => primary apnoea (responds to stimulation). • Asphyxia continues => irregular gasping efforts, which slowly decrease in frequency and eventually cease = secondary apnoea (requires PPV).

  9. OTHER PATHOPHYSIOLOGICAL CHANGES • Reduced cardiac output • Redistribution of blood • Ischaemic insult to several organs • Increased vascular permeability • Cell lysis

  10. CAUSES • Most common: • Prenatal hypoxia: • From reduced O2 supply despite adequate perfusion • Umbilical cord compression during childbirth • Preterm or difficult delivery • Maternal anaesthesia: • IV & gaseous: • Can cross the placenta and sedate the foetus

  11. HIGH RISK ANTENATAL FACTORS • Maternal diabetes • Hypertension (pregnancy induced or chronic) • Chronic maternal illness • Anaemia or Rh isoimmunisation • Previous foetal or neonatal death • Bleeding in the second or third trimester • Maternal infection • Polyhydramnios • Oligohydramnios • Low socioeconomic status • Mothers with previous abortions or preterm birth

  12. HIGH RISK ANTENATAL FACTORS • Premature rupture of membranes • Post-term gestation • Multiple gestation • Size-dates discrepancy (IUGR) • Maternal drug therapy • Maternal substance abuse (alcohol, cigaret smoking) • Foetal malformation • Diminished foetal activity • No prenatal care • Maternal age < 16 or > 40 years

  13. HIGH RISK INTRA-PARTUM FACTORS • Emergency caesarean section • Forceps or vacuum-assisted delivery • Breech or other abnormal presentation • Premature labour • Precipitous labour • Chorioamnionitis • Prolonged rupture of membranes • Prolonged labour • Prolonged second stage of labour

  14. HIGH RISK INTRA-PARTUM FACTORS • Foetal bradycardia • Non-reassuring fetal heart rate patterns • Use of general anaesthesia • Uterine tetany • Narcotics administered to mother within 4 hours of delivery • Meconium-stained amniotic fluid • Prolapsed cord • Abruptio placentae • Placenta previa

  15. Short term effects • Pulmonary • Haemorrhage • RDS: • Surfactant depletion • Aspiration • PPHN

  16. SHORT TERM EFFECTS • Cardiac • Myocardial dysfunction, valvular dysfunction, rhythm abnormalities, congestive cardiac failure • High cardiac enzymes • Renal • Acute tubular necrosis, with acute renal failure • Renal vein thrombosis & haematuria • Syndrome of inappropriate ADH secretion • Gastrointestinal • Necrotising enterocolitis, ileus, perforation • Hepatic dysfunction with hyperbilirubinaemia • Haematological • disseminated intravascular coagulation, anaemia, thrombocytopenia • Temperature instability

  17. LONG TERM EFFECTS • Long term effects: • Mainly neurological: • Severe asphyxia: • Permanent brain damage: • Cerebral palsy • Mental Retardation • Less severe asphyxia: • Seizures • Hyperactivity • Learning difficulties

  18. PREDICTION • Prenatal warning signs: • Foetal tachycardia • Late decelerations on CTG • Scalp pH < 7.2 • MSAF

  19. DIAGNOSIS • Objectively assessed using the Apgar score • Apgar scores: • One minute • Five minutes • Continue q5min if necessary (if <7) • Useful: • Can be used for formulating guidelines for post-asphyxial treatment • Predicting long term outcome: • 7 to 10 => normal • 4-6 => moderate depression • 0 to 3 => severely depressed: • Great risk of dying unless actively resuscitated

  20. Apgar Scoring

  21. MANAGEMENT OF THE ASPHYXIATED NB • Immediate: • Resuscitation • All delivery rooms should have: • Adequate resuscitation equipment and drugs • Trained personnel • Neonatal resuscitation: • An organized programme. • Most widely used: • Neonatal Resucitation Program (NRP) (preferred) • Helping baby breathe (HBB).

  22. NEONATAL RESUSCITATION GOALS • To assist with the initiation and maintenance of: • Adequate ventilation and oxygenation • Adequate cardiac output and tissue perfusion • Normal core temperature and serum glucose • May be attained more readily when: • Risk factors are identified early • Neonatal problems are anticipated • Equipment is available • Personnel are qualified and available • A care plan exists that is known by all

  23. NEONATAL RESUSCITATION-TEAM APPROACH • A team approach is important. • Appropriate preparation requires communication between midwives, OB and paeds. • At least one person capable of initiating resuscitation should attend every delivery. • When PPV and chest compressions are necessary, at least two experienced persons are needed. • Three or more trained persons would be needed if medication is required. • One ventilate, one chest compression, one drugs

  24. Neonatal Resuscitation Equipment & Drugs

  25. Neonatal Resuscitation Equipment & Drugs

  26. RESUSCITATION • Initial evaluation: gestation, amniotic fluid, breathing/cry, muscle tone => routine care or resuscitation • Initial action: • Warmth • Position to clear airway • Dry => stimulate => reposition if necessary

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